Amanda J. Abraham

Adoption and implementation of medications in addiction treatment programs.

Objectives:Little is known about the extent to which medications are being implemented as routine care in addiction treatment programs. This research describes medication adoption and implementation within the privately funded treatment sector. Methods:Face-to-face interviews were conducted with 345 administrators of a nationally representative sample of privately funded substance treatment organizations in the United States. Results:Rates of adoption of addiction treatment medications in private sector programs were lower than the adoption of psychiatric medications. Even when analyses were restricted to programs with access to physicians, adoption of each addiction treatment medication had occurred in less than 50% of programs. Within adopting programs, implementation was highly variable. Although approximately 70% of patients with cooccurring psychiatric diagnoses received psychiatric medications, rates of implementation of medication-assisted treatment for opioid dependence and alcohol use disorders were just 34.4% and 24.0%, respectively. Conclusions:Although previous research has documented higher rates of medication adoption in privately funded treatment programs, this study revealed that both adoption and implementation of pharmacotherapies to treat addiction remains modest. Future research should examine the different types of barriers to implementation, such as physician decision making, patient preferences, and system-level barriers stemming from financing and public policy.

Using Medication-Assisted Treatment for Substance Use Disorders: Evidence of Barriers and Facilitators of Implementation

The use of medications to treat substance use disorders (SUDs) has emerged as a potentially central part of the treatment armamentarium. In this paper we present data from several recent US national surveys showing that despite the clinical promise of these medications, there has been limited adoption of pharmacotherapies in the treatment of SUDs. The data reveal variable patterns of use of disulfiram, buprenorphine, tablet naltrexone, acamprosate and injectable naltrexone. After examining the environmental and institutional context for the adoption of pharmacotherapies, the specific organizational facilitators and barriers of medication adoption are considered. The paper concludes with a discussion of the minimal clinical and administrative guidance available to enhance adoption, the lack of client and consumer knowledge of medications that puts a brake on their adoption and availability, and the difficulties that must be surmounted in bringing new medications to market.

State policy influence on the early diffusion of buprenorphine in community treatment programs.

BackgroundBuprenorphine was approved for use in the treatment of opioid dependence in 2002, but its diffusion into everyday clinical practice in community-based treatment programs has been slow. This study examines the net impact of efforts by state agencies, including provision of Medicaid coverage, on program-level adoption of buprenorphine as of 2006.MethodsInterviews were conducted with key informants in 49 of the 50 state agencies with oversight responsibility for addiction treatment services. Information from these interviews was integrated with organizational data from the 2006 National Survey of Substance Abuse Treatment Services. A multivariate logistic regression model was estimated to identify the effects of state efforts to promote the use of this medication, net of a host of organizational characteristics.ResultsThe availability of Medicaid coverage for buprenorphine was a significant predictor of its adoption by treatment organizations.ConclusionInclusion of buprenorphine on state Medicaid formularies appears to be a key element in ensuring that patients have access to this state-of-the-art treatment option. Other potential barriers to the diffusion of buprenorphine require identification, and the value of additional state-level policies to promote its use should be evaluated.

Buprenorphine adoption in the National Drug Abuse Treatment Clinical Trials Network

The National Drug Abuse Treatment Clinical Trials Network (CTN), a collaborative federal research initiative that brings together universities and community-based treatment programs (CTPs), has conducted multiple clinical trials of buprenorphine for opioid dependence. Part of the CTNs mission is to promote the adoption of evidence-based treatment technologies. Drawing on a data collected during face-to-face interviews with administrators from a panel of 206 CTPs, this research examines the adoption of buprenorphine over a 2-year period. These data indicated that the adoption of buprenorphine doubled between the baseline and 24-month follow-up interviews. Involvement in a buprenorphine protocol continued to be a strong predictor of adoption at the 2-year follow-up, although adoption of buprenorphine tripled among those CTPs without buprenorphine-specific protocol experience. For-profit CTPs and those offering inpatient detoxification services were more likely to adopt buprenorphine over time. A small percentage of programs discontinued using buprenorphine. These findings point to the dynamic nature of service delivery in community-based addiction treatment and the continued need for longitudinal studies of organizational change.

Barriers to the implementation of medication-assisted treatment for substance use disorders: the importance of funding policies and medical infrastructure.

Despite growing interest in the use of evidence-based treatment practices, adoption of pharmacotherapies for treating substance use disorders (SUDs) remains modest. Using data from telephone interviews with 250 administrators of publicly funded SUD treatment programs, this study estimated a model of adoption of medication assisted treatment (MAT) for SUDs and examined the relative importance of regulatory, cultural, medical resource, patient-level, and funding barriers to MAT implementation. MAT-adopting programs had significantly greater medical resources, as measured by the employment of physicians and nurses, than non-adopting programs. Administrators of non-adopting programs were asked to rate the importance of 18 barriers to MAT implementation. The most strongly endorsed barriers were regulatory prohibitions due to the programs lack of medical staff, funding barriers to implementing MAT, and lack of access to medical personnel with expertise in delivering MAT. Barriers related to insufficient information about MAT and unsupportive staff attitudes were not widely endorsed. These findings suggest that efforts to promote the implementation of MAT that are inattentive to funding barriers and weaknesses in medical infrastructure may achieve sub-optimal results.

Despite Resources From The ACA, Most States Do Little To Help Addiction Treatment Programs Implement Health Care Reform

The Affordable Care Act (ACA) dramatically expands health insurance for addiction treatment and provides unprecedented opportunities for service growth and delivery model reform. Yet most addiction treatment programs lack the staffing and technological capabilities to respond successfully to ACA-driven system change. In light of these challenges, we conducted a national survey to examine how Single State Agencies for addiction treatment--the state governmental organizations charged with overseeing addiction treatment programs--are helping programs respond to new requirements under the ACA. We found that most Single State Agencies provide little assistance to addiction treatment programs. Most agencies are helping programs develop collaborations with other health service programs. However, fewer than half reported providing help in modernizing systems to support insurance participation, and only one in three provided assistance with enrollment outreach. In the absence of technical assistance, it is unlikely that addiction treatment programs will fully realize the ACAs promise to improve access to and quality of addiction treatment.

Organizational factors associated with the use of contingency management in publicly funded substance abuse treatment centers

A promising area within technology transfer studies is the identification of organizational factors that influence the adoption of treatment innovations. Although studies have identified organizational factors associated with the adoption of pharmacological innovations, few studies have examined organizational factors in the adoption of psychosocial innovations, among which contingency management (CM) is a significant practice. Using data from a sample (N = 318) drawn from the population of publicly funded treatment centers in the United States, this study modeled organizational factors falling in the domains of structural characteristics, workforce variables, values and norms, and patient characteristics associated with the use of CM. Organizations were more likely to use CM if they embrace a supportive therapeutic approach, are research friendly, offer only outpatient levels of care, or serve drug-court patients. Implications for studying the diffusion and implementation of evidence-based psychosocial interventions are discussed.

The adoption of alcohol pharmacotherapies in the Clinical Trials Network: The influence of research network participation

Organizational participation in clinical research may lead to adoption of the intervention by treatment agencies, but it is not known whether research involvement enhances innovativeness beyond the specific interventions that are tested. The National Institute on Drug Abuses Clinical Trials Network (CTN) is a platform for considering this research question. To date, the CTN has not conducted research on medications for alcohol use disorders (AUDs), so greater adoption of innovative AUD pharmacotherapies by CTN-affiliated programs would suggest an added value of research network participation. Using longitudinal data from a pooled sample of CTN and non-CTN publicly funded treatment programs, we investigate adoption of tablet naltrexone and acamprosate over a 2-year period. CTN-affiliated programs were more likely to have adopted tablet naltrexone and acamprosate at 24-month follow-up, net of the effects of a range of organizational characteristics. Research network participation may thus enhance organizational innovativeness to include interventions beyond the scope of the network.

A multi-level analysis of counselor attitudes toward the use of buprenorphine in substance abuse treatment.

Despite evidence that buprenorphine is effective and safe and offers greater access as compared with methadone, implementation for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This study uses hierarchical linear modeling to examine National Treatment Center Study data to identify counselor characteristics (attitudes, training, and beliefs) and organizational factors (accreditation, caseload, access to buprenorphine, and other evidence-based practices) that influence implementation of buprenorphine for treatment of opiate dependence. Analyses showed that provider training about buprenorphine, higher prevalence of opiate-dependent clients, and less treatment program emphasis on a 12-step model predicted greater counselor acceptance and perceived effectiveness of buprenorphine. Results also indicate that program use of buprenorphine for any treatment purpose (detoxification, maintenance, and/or pain management) and time (calendar year in data collection) was associated with increased diffusion of knowledge about buprenorphine among counselors and with more favorable counselor attitudes toward buprenorphine.

A Systematic Review on the Use of Psychosocial Interventions in Conjunction with Medications for the Treatment of Opioid Addiction

Opioid use and overdose rates have risen to epidemic levels in the United States during the past decade. Fortunately, there are effective medications (ie, methadone, buprenorphine, and oral and injectable naltrexone) available for the treatment of opioid addiction. Each of these medications is approved for use in conjunction with psychosocial treatment; however, there is a dearth of empirical research on the optimal psychosocial interventions to use with these medications. In this systematic review, we outline and discuss the findings of 3 prominent prior reviews and 27 recent publications of empirical studies on this topic. The most widely studied psychosocial interventions examined in conjunction with medications for opioid addiction were contingency management and cognitive behavioral therapy, with the majority focusing on methadone treatment. The results generally support the efficacy of providing psychosocial interventions in combination with medications to treat opioid addictions, although the incremental utility varied across studies, outcomes, medications, and interventions. The review highlights significant gaps in the literature and provides areas for future research. Given the enormity of the current opioid problem in the United States, it is critical to gain a better understanding of the most effective ways to deliver psychosocial treatments in conjunction with these medications to improve the health and well-being of individuals suffering from opioid addiction.